Hysteroscopic myomectomy: a comprehensive review of surgical techniques

Hysteroscopic myomectomy currently represents the standard minimally invasive surgical procedure for treating submucous fibroids, with abnormal uterine bleeding and reproductive issues being the most common indications. While hysteroscopic myomectomy has been shown to be safe and effective in the control of menstrual disorders, its effects on infertility remain unclear. The review provides a comprehensive survey of all hysteroscopic techniques used to treat fibroids found completely within the uterine cavity (G0) and those with intramural development (G1 and G2). MEDLINE and EMBASE searches identified published papers from 1970. The choice of the technique mostly depends on the intramural extension of the fibroid, as well as on personal experience and available equipment. 'Resectoscopic slicing' still represents the 'gold standard' technique for treating fibroids G0, even if several other effective techniques including ablation by neodymium-yttrium-aluminum-garnet laser, morcellation and office myomectomy have been proposed. On the other hand, the present review clearly indicates that there is still no single technique proven to be unequivocally superior for treating fibroids G1 and G2. Most techniques aim at the transformation of an intramural fibroid into a totally intracavitary lesion, thus avoiding a deep cut into the myometrium. At present, the 'cold loop' technique seems to represent the best option as it allows a safe and complete removal of such fibroids in just one surgical procedure, while respecting the surrounding healthy myometrium.